Price: Rs. 70/- Appl. No.

_____________

PÀ£ÁðlPÀ «±Àé«zÁå®AiÀÄ, zsÁgÀªÁqÀ Passport Size

Karnatak University, Dharwad Photograph

¥ÀzÀ« ¥ÀæªÀiÁt ¥ÀvÀæ ¥ÀqÉAiÀÄ®Ä ¸À°¸

è ÀĪÀ Cfð
Application Form for Degree Certificate

1. ¥ÀzÀ«AiÀÄ ºÉ¸ÀgÀÄ
ªÁ¶ðPÀ / «±ÉõÀ WÀnPÉÆÃvÀìªÀzÀ ¥ÀzÀ« ¥ÀæzÁ£À Name of the Degree____________________
Annual / Special Convocation for Conferring Degrees 2. ¥Á¸ÁzÀ ±ÉæÃtÂ
PÀÄ®¸ÀaªÀgÀÄ(ªÀiË®åªÀiÁ¥À£À), PÀ£ÁðlPÀ «±Àé«zÁå®AiÀÄ, zsÁgÀªÁqÀ Class obtained ________________
The Registrar(Evaluation), Karnatak University, Dharwad 3. ¥Á¸ÁzÀ ªÀµÀð
Year of passing ________________________
4. ¥sÀ°vÁA±À ¥ÀæPÀn¹zÀ ¢£ÁAPÀ
Date of declaration of result _____________

ªÀiÁ£ÀågÉ,
Sir,
£Á£ÀÄ _______________gÀ r¸ÉA§gÀ/ªÀiÁZÀð wAUÀ½£À°è £ÀqÉAiÀÄ°gÀĪÀ «±Àé«zÁå®AiÀÄzÀ WÀnPÉÆÃvÀìªÀzÀ°è ¥ÀzÀ« ¥ÀqÉAiÀÄ®Ä Cfð ¸À°è¸ÀÄwÛzÉÝãÉ.
I am applying for the Degree at the University Convocation to be held in December / March _________________

F PɼÀUÉ £ÀªÀÄÆ¢¹zÀ ¥ÀzÀ«AiÀÄ ¥ÀæªiÀ Át ¥ÀvæÀ PÉÆÃj £Á£ÀÄ EzÀPÀÆÌ ªÉÆzÀ®Ä Cfð ¸À°è¹gÀĪÀ¢®è.
I have not applied for conferring the Degree mentioned below prior to this application.

£Á£ÀÄ ¥ÀzÀ« ¥ÀæªiÀ Át ¥ÀvæPÀ ÉÌ CUÀvÀå«gÀĪÀ J®è ªÀiÁ»wUÀ¼À£ÀÄß F PɼÀUÉ PÁt¹zÉÝãÉ.

All the particulars required for conferring the degree are prescribed below :
C.£ÀA. «ªÀgÀUÀ¼ÀÄ C¨sÀåyðAiÀÄÄ ¨sÀwð ªÀiÁqÀ¨ÉÃPÀÄ
Sl. No. Particulars To be filled by the candidate
C¨sÀåyðAiÀÄ ¥ÀÆtð ºÉ¸ÀgÀÄ (CAPÀ¥ÀnÖAiÀÄ°èzÀÝAvÉ)
1
Name of the candidate(as per Marks Card)
UÀAqÉÆÃ/ºÉuÉÆÚÃ
2
Male / Female
ªÀĺÁ«zÁå®AiÀÄzÀ ºÉ¸ÀgÀÄ, PÉÆÃqÀ £ÀA./¸ÁßvÀPÉÆÃvÀÛgÀ «¨sÁUÀzÀ ºÉ¸ÀgÀÄ
3
Name of the College with code No. /P.G. Dept.
C¨sÀåyðAiÀÄÄ ¥ÀqÉAiÀÄ°gÀĪÀ ¥ÀzÀ« / r¥ÉÆèêÀiÁzÀ ºÉ¸ÀgÀÄ
4
Name of the Degree/ Diploma for which applied
¥Á¸ÁzÀ ªÀUÀð
5
Class obtained
¥ÀjÃPÉëUÉ PÀĽvÀ ¸ÀܼÁAPÀ
6
Exam. Seat No.
¥ÀjÃPÉë ¥Á¸ÁzÀ wAUÀ¼ÀÄ ªÀÄvÀÄÛ ªÀµÀð
7
Month & year of passing the examination
¤AiÀÄ«ÄvÀ «zÁåyðAiÀiÁV / ¨ÁºÀå C¨sÀåyðAiÀiÁV
8 ¥ÀjÃPÉëAiÀÄ£ÀÄß ¥Á¸ÁVgÀĪÀzÀÄ
As a Regular/ External candidate
G¥À¹ÜvÀjzÀÄÝ / C£ÀÄ¥À¹ÜvÀjzÀÄÝ ¥ÀzÀ« ¥ÀqÉAiÀÄ®Ä CºÀðjgÀĪÀgÀÄ
9 Whether applicant held eligible to take the Degree in
“Person” or in “Absentia”
gÁ¶ÖçÃAiÀÄvÉ
10
Nationality
zÀÈrüÃPÀÈvÀ CAwªÀÄ ªÀµÀðzÀ ¥Á¸ÁzÀ CAPÀ¥ÀnÖAiÀÄ£ÀÄß
F WÀnPÉÆÃvÀìªÀzÀ CfðAiÀÄ eÉÆvÉUÉ ®UÀwÛ¸À¨ÉÃPÀÄ.
11
Attested copy of the Final year Marks Card should be
enclosed with the Convocation Application.
----------------------------------------------------------------------------------------------------------------------------------------------------
ACKNOWLEDGEMENT
Sl. No. of Application: ________________

Received the Convocation application form from Shri/Smt. _____________________________________________

______________________________________________for the Degree of ________________________________________
today the _____________________________________________

1. Degree : _____________________

2. Class : _____________________ Enquiry Counter

Examination Section
3. Year of passing : _____________________ Karnatak University, Dharwad

4. Date of declaration : _____________________

Note: BRING THE ATTESTED COPIES OF THE FINAL YEAR MARKS CARD AND CONVOCATION FEES
PAID CHALLAN/D.D. FOR ENQUIRY IN.
 2

¥ÀÆtð ºÉ¸ÀgÀÄ (PÉÆ£ÉAiÀÄ ªÀµÀðzÀ CAPÀ ¥ÀnÖAiÀÄ°è EzÀÝAvÉ) (PÀ£ÀßqÀ ªÀÄvÀÄÛ EAVèõÀ ¨sÁµÉAiÀÄ°è §gɬÄj.)
Full name (as per Final Year Marks Card) (Write in Kannada and English version)

1. C¨sÀåyðAiÀÄ ºÉ¸ÀgÀÄ :
Name of the candidate

2. vÀAzÉAiÀÄ ºÉ¸ÀgÀÄ :
Father’s name

3. vÁ¬ÄAiÀÄ ºÉ¸ÀgÀÄ :
Mother’s name

4. CqÀØ ºÉ¸ÀgÀÄ :
Surname

«. ¸ÀÆ. 1. ¥ÀzÀ« ¥ÀæªÀiÁt ¥ÀvæªÀ À£ÀÄß PÀ£ÀßqÀ ºÁUÀÆ DAUÀè¨sÁµÉAiÀÄ°è ¤ÃqÀ°zÀÄÝ, C¨sÀåyðAiÀÄÄ WÀnPÉÆÃvÀìªÀPÉÌ CfðAiÀÄ£ÀÄß ¸À°è¸ÀĪÁUÀ
CAPÀ¥ÀnÖAiÀÄ°è £ÀªÀÄÆ¢¹zÀAvÉ vÀªÀÄä ¥ÀÆtð ºÉ¸ÀgÀ£ÀÄß PÀ£ÀßqÀ ºÁUÀÆ EAVèõÀ JgÀqÀÆ ¨sÁµÉAiÀÄ°è ¸ÀàµÀÖªÁV §gÉAiÀÄĪÀÅzÀÄ.

2. C¨sÀåyðAiÀÄÄ ºÀÄAr(rªÀiÁAqÀ qÁæ¥sÀÖ) AiÀÄ »A§¢AiÀÄ°è vÀ£Àß ºÉ¸ÀgÀ£ÀÄß ¸ÀàµÀÖªÁV £ÀªÀÄÆ¢¸ÀĪÀÅzÀÄ. ºÀÄArAiÀÄÄ zsÁgÀªÁqÀzÀ°è
¥ÁªÀwAiÀiÁUÀĪÀAwgÀ¨ÉÃPÀÄ.

Special Instructions :

1. While filling application for convocation the candidate should write his/her name both in Kannada and English
version, so as to enable us to write his/her name in the Degree Certificate.

2. The candidate must write his/her name on the back side of the Demand Draft. The Demand Draft must be payable at Dharwad.

UÉÆvÀÄÛ¥Àr¹zÀ ±ÀÄ®Ì gÀÆ. _______________ «±Àé«zÁå®AiÀÄzÀ°è £ÀUÀzÁV/ZÀ®£ï ªÀÄÄSÁAvÀgÀ CxÀªÁ “«vÁÛ¢üPÁjUÀ¼ÀÄ, PÀ£ÁðlPÀ «±Àé«zÁå®AiÀÄ,
zsÁgÀªÁqÀ” EªÀgÀ ºÉ¸ÀjUÉ ºÀÄAr (rªÀiÁAqÀ qÁæ¥ÀsÖ) £ÀA. ________________ ¢£ÁAPÀ ______________________ ªÀÄÆ®PÀ vÀÄA§¯ÁVzÉ.

The prescribed fees of Rs. _________________ is paid in cash/Challan at the University office or in the form of Demand Draft
bearing No. ______________ dated ______________ drawn in favour of the “Finance Officer, Karnatak University, Dharwad”, payable at
Dharwad.

ªÉÄð£À ºÉýPÉAiÀÄÄ ¸ÀªÀÄ¥ÀðPÀªÁVzÉAiÉÄAzÀÄ £Á£ÀÄ F ªÀÄÆ®PÀ WÉÆö¸ÀÄvÉÛãÉ.

I declare that the statements made above are correct.

vÀªÀÄä «±Áé¹
Yours faithfully

C¨sÀåyðAiÀÄ ¸À»
Signature of the candidate
CAZÉ «¼Á¸À: Address for correspondence (in capital) :

____________________________________________

____________________________________________

____________________________________________

------------------------------------------------------------------------------------------------------------------------------------------------------------------------
 3

1. ªÀÄzÀĪÉAiÀiÁzÀ ºÉtÄÚ ªÀÄPÀ̼ÀÄ UÀAqÀ£À ºÉ¸ÀgÀ£ÀÄß ¥ÀqÉzÀÄPÉÆAqÀ CxÀªÁ AiÀiÁªÀÅzÉà ªÀåQÛ ¨ÉÃgÉAiÀĪÀjUÉ zÀvÀÄÛ ºÉÆÃzÀ ¥Àæ¸ÀAUÀªÀ£ÀÄß ºÉÆgÀvÀÄ¥Àr¹ ºÉ¸Àj£À°è §zÀ¯ÁªÀuÉ
ªÀiÁqÀĪÀÅzÀPÉÌ C£ÀĪÀÄw¬Ä®èzÉ «zÁåyðUÀ¼ÀÄ F ªÉÆzÀ®Ä «±Àé«zÁå®AiÀÄzÀ°è zÁR¯ÁzÀ ºÉ¸Àj£ÉÆA¢UÉ ¥ÀvÀæ ªÀåªÀºÁgÀ ªÀiÁqÀ¨ÉÃPÀÄ.
Change in name is not permitted as in the case of women adopting the name of her husband or in the case of person changing the name
after he goes in adoption to some other person. The candidate should however correspond with the name that is already recorded in the
University.

2. C¨sÀåyðUÀ¼ÀÄ vÀªÀÄä ºÉ¸ÀgÀ£ÀÄß ¸ÀàµÀÖªÁV §gÉAiÀĨÉÃPÀÄ. CfðAiÀÄ°è §gÉzÀ ºÉ¸ÀgÀÄ «±Àé«zÁå®AiÀÄzÀ zÁR¯ÉAiÀÄ°è £ÀªÀÄÆ¢¸À¯ÁzÀ ºÉ¸ÀjUÉ ¸Àj ºÉÆAzÀ¢zÀÝ°è ¸ÀzÀgÀ
Cfð gÀzÁÝUÀĪÀzÀÄ. MAzÀÄ ªÉÃ¼É C¨sÀåyðAiÀÄ ºÉ¸Àj£À §zÀ¯ÁªÀuÉUÉ PÀ£ÁðlPÀ «±Àé«zÁå®AiÀÄzÀ PÀÄ®¸ÀaªÀgÀÄ C£ÀĪÀÄw PÉÆnÖzÀÝ°è D ¥ÀvÀæzÀ ªÀÄÆ® ¥ÀæwAiÀÄ£ÀÄß
CªÀ£ÀÄ/CªÀ¼ÀÄ CfðAiÀÄ eÉÆvÉUÉ ºÁdgÀ ¥Àr¸À¨ÉÃPÀÄ.
Candidates shall write their names legibly. If the name written in the application does not tally exactly with that of the University records,
the application will be rejected unless the candidate submits with the application the original letter from the Registrar, Karnatak University
permitting him/her for the change in name.

3. C¨sÀåyðAiÀÄÄ vÀ£Àß «¼Á¸ÀªÀ£ÀÄß ¥ÀÄl¸ÀASÉå 02 ªÀÄvÀÄÛ 04 gÀ°è CªÀ±ÀåªÁV £ÀªÀÄÆ¢¸ÀĪÀÅzÀÄ.

Address should be written by the candidate on page no. 2 and 4 compulsorily.

4. ¥ÀæxÀªÀÄ ªÀUÀðzÀ°è ¥Àæ±À¹Û ¸À»vÀ ¥ÀqÉzÀ ¸ÁÜ£,À ¥ÀæxÀªÀÄ ªÀUÀð, ¢éwÃAiÀÄ ªÀUÀð CxÀªÁ ¸ÁªÀiÁ£Àå (vÀÈwÃAiÀÄ) ªÀUÀðzÀ°è ¥Á¸ÁzÀÄzÀPÉÌ PÀæªÀiÁAPÀ 5 gÀ JzÀÄjUÉ
£ÀªÄÀ Æ¢¸ÀĪÀÅzÀÄ.
Write “First Class with Distinction, First, Second or Pass” as the case may be against item No. 5.

5. JA.©.©.J¸ï./©.¥sÁªÀiÁð./©.J.JA.J¸ï./©.r.J¸ï./©.JZï.JªÀiï.J¸ï./©.¦.n. ¥Àz«
À AiÀÄ C¨såÀ yðUÀ¼ÀÄ ºË¸ÀªÄÀ £ï ²¥ï ¥ÀÆwðUÉƽ¹zÀ §UÉUÉ
«±Àé«zÁå®AiÀÄ¢AzÀ ¥ÀqÉzÀ ¥ÀæªiÀ Át ¥ÀvæÀ ®UÀwÛ¸ÀĪÀÅzÀÄ.
Candidates of M.B.B.S. /B.Pharma/B.A.M.S./B.D.S./B.H.M.S. and B.P.T. courses have to enclose their compulsory Housemanship
Completion Certificate issued by the University.

¥ÀzÀ«, ¸ÁßvÀPÉÆÃvÀÛgÀ ¥ÀzÀ« ºÁUÀÆ r¥ÉÆèêÀiÁUÀ½UÉ ¸ÀA§A¢ü¹zÀ ¥ÀæªÉñÀ ±ÀĮ̪ÀÅ F PɼÀV£ÀAwzÉ :

Following are the Fees for issue of Original Degree Certificate of all the Degrees and Diploma Courses :

1. J®è ¤AiÀÄ«ÄvÀ ¸ÁßvÀPÉÆÃvÀÛgÀ, ¸ÁßvÀPÉÆÃvÀÛgÀ r¥ÉÆèêÀiÁ ºÁUÀÆ gÁåAPÀ «eÉÃvÀ ¥ÀzÀ« C¨sÀåyðUÀ¼ÀÄ ¨ÁºÀå C¨sÀåyðUÀ¼À£ÀÄß
ºÉÆgÀvÄÀ ¥Àr¹ ¸ÀªÄÀ PÀëªÄÀ ¥Àz«
À ¥ÀqÉAiÀÄ®Ä (¥Àæ¸ÀÄÛvÀ ±ÉÊPÀëtÂPÀ ªÀµÀðzÀ°è GwÛÃtðgÁzÀ «zÁåyðUÀ½UÉ ªÀiÁvÀæ)
In person - all regular P.G./ P.G. Diploma candidates & Rank holders in a 495-00
Bachelor Degrees except External candidates (Current year sucessful candidates only)

2. J®è ¸ÁßvÀPÉÆÃvÀÛgÀ, ¸ÁßvÀPÉÆÃvÀÛgÀ r¥ÉÆèêÀiÁ ºÁUÀÆ ¥ÀzÀ« C¨sÀåyðUÀ¼ÀÄ C£ÀÄ¥À¹ÜvÀ ¥ÀzÀ« ¥ÀqÉAiÀÄ®Ä (ªÀiÁvÀæ)
In Absentia - P.G./P.G. Diploma & Bachelor Degree candidates only a 660-00

1. G¥À¹ÜvÀ - ¸ÁßvÀPÉÆÃvÀÛgÀ «zÉò «zÁåyðUÀ½UÉ ªÀiÁvÀæ 77 qÁ®gïUÀ¼ÀÄ

2. C£ÀÄ¥À¹ÜvÀ - J®è ¥ÀzÀ«AiÀÄ «zÉò «zÁåyðUÀ½UÉ 110 qÁ®gïUÀ¼ÀÄ
3. «zÉò «zÁåyðUÀ½UÉ WÀnPÉÆÃvÀìªÀ Cfð ±ÀÄ®Ì 12 qÁ®gïUÀ¼ÀÄ
(i) In person PG foreign students only US $ 77-00*
(ii) In Absentia for all U.G. courses Foreign students only US $ 110-00*
(iii) Application fees for Foreign National students US $ 12-00*

3. »A¢£À ªÀµÀðUÀ¼À°è vÉÃUÀðqÉAiÀiÁzÀªÀgÀÄ Cfð ¸À°è¸À§ºÀÄzÀÄ. DzÀgÉ ±ÀÄ®ÌzÀ «ªÀgÀªÀ£ÀÄß «ZÁgÀuÁ ªÀĽUÉ, WÀnPÉÆÃvÀìªÀ «¨sÁUÀ ºÁUÀÆ ªÉ¨ï¸ÉÊmï£À°ègÀĪÀ
±ÀÄ®ÌzÀ AiÀiÁ¢¬ÄAzÀ ¥ÀqÉAiÀħºÀÄzÀÄ.
Successful candidates belonging to previous years are also eligible to apply for the ensuing Convocation, however they are required to
obtain the information about convocation fees from the Counter/ Convocation Section/chart in the website.
 4
«.¸ÀÆ.
*1. «zÉò «zÁåyðUÀ¼ÀÄ ±ÀÄ®ÌzÀ ºÀtªÀ£ÀÄß qÁ®gïUÀ½UÉ ¸ÀªÀÄ£ÁzÀ ¨sÁgÀwÃAiÀÄ gÀÆ¥Á¬ÄUÀ¼À°è ¥ÁªÀw¸À§ºÀÄzÀÄ.

2. WÀnPÉÆÃvÀìªÀzÀ ±ÀĮ̪À£ÀÄß ZÀ®£ÀzÀ°ègÀĪÀ PÉÆÃqÀ £ÀA. 719PÉÌ ¨sÀj¸ÀĪÀÅzÀÄ.

3. ¥ÀzÀ« ¥ÀæªÀiÁt¥ÀvæUÀ À¼À£ÀÄß ¸ÀªÀÄPÀëªÀÄ ¥ÀqÉAiÀÄ®Ä Cfð ¸À°è¹ WÀnPÉÆÃvÀìªÀzÀ ¢£ÀzÀAzÀÄ ¥ÀzÀ« ¥ÀæªÀiÁt¥Àvæª
À À£ÀÄß ¥ÀqÉAiÀÄ¢zÀÝ°è
CAxÀªÀgÀ£ÀÄß UÉÊgÀºÁdj(C£ÀÄ¥À¹Üw) C¨sÀåyðUÀ¼ÉAzÀÄ ¥ÀjUÀt¸À¯ÁUÀĪÀzÀÄ ªÀÄvÀÄÛ CAxÀªÀgÀÄ C£ÀÄ¥À¹ÜwAiÀÄ ±ÀĮ̪À£ÀÄß vÀÄA§¨ÉÃPÁUÀĪÀzÀÄ.

Special Instructions:

* 1. The foreign students can pay the equivalent amount of fees in Indian currency.

2. Those who use the challans need to remit the convocation fee to Code No. 719.

3. The persons who have applied for conferring of the degree certificate in person but did not obtain his/her
certificate on convocation day, will be treated as in absentia and they will have to pay absentia fees.

__________________________________________________________________________________________________________

PÀZÉÃjAiÀÄ°è ¨sÀwð ªÀiÁqÀĪÀzÀÄ :

To be filled in by the Office :

1. ¥s°
À vÁA±À ¥ÀæPÀn¹zÀ ¢£ÁAPÀ : Date Month Year C¢üÃPÀëPÀgÀÄ, ¸ÀA§A¢ü¹zÀ «¨sÁUÀ

Result declared on : O. S. Concerned Branch

2. WÀnPÉÆÃvÀìªÀzÀ CfðAiÀÄ£ÀÄß ¥Àj²Ã°¹zÀªÀgÀÄ ¸À»/ Signature ____________________________

Convocation application verified by

ºÉ¸ÀgÀÄ / Name

From:-

The Registrar(Evaluation)
Karnatak University,
Pavate Nagar, Dharwad-580 003
Karnataka – India.

Candidate’s address for despatch of degree certificate ( in capital letters)

---------------------------------------------------------------------------------------------------------------------------------------------------------------

O.I.G.S.
Karnatak University, Dharwad

To _______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________